Goal met. Pt demonstrated clear lung fields
and no evidence of crackles upon assessment. Pt stated she felt like she was able
to breath better and she stated that she was experiencing a much m ore productive
cough than before. Pt said she thought the breathing exercises really helped out.

Continue interventions as listed. Continue
to encourage deep breathing and coughing exercises. Continue to encourage small
meals and needed supplements.

Goal met. Pt demonstrated improved ventilation upon assessment. Pt stated that she
felt like she could breathe much better by the end of shift. She stated she felt
like she was having a much more productive cough and getting the mucus up better.
Pt’s O2 sat also remained at 96% and did not drop throughout the shift. The nurse
stated that the pt’s O2 sat today, was better than it had been since she was admitted
on Month 27th, Year.